New Review Tracks ‘Evolving’ CV Impact of COVID-19 on Patients, Hospitals

In a rapidly changing environment, a new review attempts to characterize the cardiovascular impact of COVID-19, including its potential consequences on patients with and without established cardiovascular disease, as well as on hospital systems that are bracing to be strained to the hilt by a flood of patients infected with the virus.

The review, which was led by Elissa Driggin, MD, Mahesh Madhavan, MD, and senior investigator Sahil Parikh, MD (all from NewYork-Presbyterian/Columbia University Irving Medical Center, New York, NY), is an attempt to pull together what’s known, what’s not, and what needs to happen next.  

“This is an evolving situation where even the best-laid plans can rapidly change,” Parikh told TCTMD. “We need to respect the disease and respect the fact that we need to protect ourselves as healthcare providers. We need to be specifically cognizant of the nonpulmonary manifestations of this illness and that we’re not forgetting about the routine things that will continue to happen, which will either be deferred or delayed because of our attention being paid to [COVID-19]. We are hoping that people will educate themselves, as they always do, and that will better prepare us to take of our patients.”

For Madhavan, the report is an attempt to consolidate the existing cardiovascular literature with respect to the virus, all with the understanding that more data is being collected and published on a daily basis. “We wanted to get information out there as quickly as we can, to get people aware of all the potential issues at play with this virus and how it can certainly affect a number of systems in the body, especially the cardiovascular system,” he told TCTMD.

The Centers for Disease Control and Prevention (CDC) is reporting that as of March 20, 2020, there are 15,219 diagnosed cases of COVID-19 and 201 deaths in the United States, but the number of cases grows by thousands as they update their numbers daily. Johns Hopkins University is currently reporting 16,638 diagnosed cases in the US and more than 266,000 cases worldwide. The total number of deaths globally is more than 11,100 and rising.

Getting a Handle on Things (or Trying)

In the paper, which was published March 19, 2020, in the Journal of the American College of Cardiology and includes input from physicians in different specialties, including interventional cardiology, general cardiology, heart failure, vascular medicine, pharmacy, and health policy, the reviewers point out that the majority of data to date are from China, the original epicenter of the disease, and in some instances from Italy, a country that has been hard-hit by the pandemic. 

This is an evolving situation where even the best-laid plans can rapidly change. Sahil Parikh

Overall, the prevalence of underlying CVD in patients with COVID-19 appears to range from as low as 4.0% to as high as 14.6%. Increased case-fatality rates in 44,672 confirmed COVID-19 cases from Wuhan, China, were documented in patients with CVD (10.5%), diabetes (7.3%), and hypertension (6.0%). These fatality rates are notably higher than the 2.3% reported in the general COVID-19 patient population. Early data from Italy also suggest there is an increased risk of death in patients with COVID-19 and underlying comorbidities.

There are several reports that infection can lead to cardiovascular complications or exacerbate preexisting CVD. For patients who develop severe respiratory infection, especially if they have acute respiratory distress syndrome caused by COVID-19, myocardial injury is likely to occur. Other early reports have suggested evidence of acute myocarditis. While data in the setting of ACS is limited, the inflammatory response and hemodynamic changes resulting from COVID-19 may place susceptible patients at risk for plaque rupture, according to the review. Additionally, cardiac arrhythmias are reportedly common in patients with COVID-19 infection, particularly in those with severe illness requiring an ICU stay, and heart failure was seen in 23.0% of patients with COVID-19 in one Chinese series.

Several antiviral agents are currently being tested for COVID-19, some of which are known to interact with other cardiovascular medications or potentially cause cardiac effects. For example, the combination of lopinavir and ritonavir, which has been used in the treatment of HIV/AIDS, can alter the heart’s electrical conduction system and cause myopathy and rhabdomyolysis when used with statins. Other drugs, like bevacizumab and chloroquine/hydroxychloroquine, can cause myocardial toxicity.

The implications of using ACE inhibitors or angiotensin receptor blockers (ARBs) while infected with COVID-19, or whether use of the drugs increase susceptibility to the virus, is unknown. There had been some concern about ACE inhibitor/ARB therapy because the virus enters human cells via the ACE2 receptor, and while much is still uncertain, the Heart Failure Society of America (HFSA), the American College of Cardiology (ACC), and the American Heart Association (AHA), as well as European and Canadian experts, do not recommend stopping therapy in patients with COVID-19.

Taking Care of the Providers

The review also provides physicians, nurses, and other staff with some hard direction in treating patients in the era of COVID-19.

For one, the co-authors warn that additional personal protective equipment (PPE) may be needed during procedures that generate aerosols, such as transesophageal echocardiography, endotracheal intubation, or CPR and bag-mask ventilation. Face masks, eye protection, gown, and gloves are necessary as per recommendations from the CDC and World Health Organization (WHO). One consideration for interventionalists and cardiac surgeons is the possibility of converting cath labs and operating rooms to negative-pressure ventilation, which has been done by some centers in China.

I hope measures are taken from national and local leadership to do as much as possible to get us the protection that we need to give these patients the care that they deserve. Mahesh Madhavan

Necessary steps will be very different from those for cases they routinely perform. “We really need to think about how to protect ourselves,” said Parikh. “We frequently ignore that and we get away with that all time. It’s not as though we’re always running into a burning building like our fire-and-rescue colleagues, but in this case it feels an awful lot like that.”

Madhavan also stressed the importance of taking all necessary precautions when treating patients.

“All of us came into this [profession] with a wholehearted intention to help others and many of us have done this in a manner that puts the patient above our own individual interests,” he said. “However, this is a circumstance where healthcare workers need to realize their importance and value in caring for patients. Staying healthy, staying safe, and, as much as possible, being protected is of equal importance to treating that individual patient.”

The increasing number of COVID-19 cases presenting to their emergency department is concerning, said Madhavan, especially with more cases still to come. “Fortunately, temporarily we have all the things we need,” he said. “But it’s anticipated nationally, as well as internationally, that might not be the case in the coming weeks. I hope measures are taken from national and local leadership to do as much as possible to get us the protection that we need to give these patients the care that they deserve.”    

Telemedicine, in this time of extreme circumstance, is also strongly encouraged to stop the spread of transmission. To TCTMD, Parikh noted they have a lot of [COVID-19] patients already in the hospital and this had led to substantial changes, including the cancelation of elective procedures and outpatient visits. If an intervention must be performed, the cath lab needs to be thoroughly cleaned, which could lead to treatment delays.

Madhavan noted there are reports of individual centers changing up STEMI pathways, such as utilizing fibrinolytic therapy if delays to primary PCI are anticipated because a hospital is at capacity or staffing in the cath lab in inadequate. “That certainly poses a challenge because the field has evolved so much over the past 20 or 30 years, where we know revascularization with stents is going to help people with STEMI,” he said. “There is certainly potential for significant hemorrhagic complications with lytic therapy. There’s going to need to be a balance in figuring out individual hospital protocols and how best to negotiate this as the virus becomes more prevalent in the United States.”

It is very important, he added, that national societies, such as the ACC and the Society for Cardiovascular Angiography and Interventions (SCAI), help provide guidance, which they have already started to do with respect to revascularization and cath lab staffing. As of now, SCAI still recommends primary PCI for patients with confirmed COVID-19 as long as appropriate infectious disease protection is in place for the entire cath lab team. SCAI does suggest putting off elective procedures for now and said they expect to update their recommendations as more information becomes available.